Transvaginal Ultrasonography and Hysteroscopy As Predictors of Endometrial Polyps in Postmenopause

Research Article de Godoy Borges, Dias, Bonassi Machado, BorgesEndometrial & Spadoto polyp Dias in postmenopause

11 Research Article Transvaginal ultrasonography and hysteroscopy as predictors of endometrial polyps in postmenopause

Womens Health The study compared ultrasound and ambulatorial hysteroscopy as diagnostic Pítia Cárita de Godoy methods detecting endometrial polyps in postmenopause women. 281 women aged Borges*,1,3, Rogério Dias2, 41–82 years who underwent ambulatorial hysteroscopy were analyzed for presence Rogério Bonassi Machado1, 1 of uterine bleeding and/or altered transvaginal ultrasound (endometrial thickness João Bosco Ramos Borges & Daniel Spadoto Dias3 ≥5 mm). Ultrasonography detected endometrial polyps in 22.8% of patients and 1Department of Gynecology & Obstetrics, endometrial thickening in the other 59.8%. Hysteroscopy diagnosed endometrial Faculdade de Medicina de Jundiaí, polyps in 80.8%. Ultrasonography showed sensitivity of 88.7%, specificity of 25.4%, São Paulo, Brasil positive predictive value of 81.7%, negative predictive value of 37.5% and accuracy 2Department of Gynecology, Obstetrics, of 75.4% in diagnosing endometrial polyps. Hysteroscopy showed 96.4% sensitivity, & Mastology, Faculdade de Medicina de 74.6% specificity, 93.4% positive predictive value, 84.6% negative predictive value and Botucatu, Universidade Estadual Paulista (UNESP), Botucatu, SP, Brazil 91.8% accuracy. Hysteroscopy demonstrated more accuracy than ultrasonography, 3Post Graduation Program in Gynecology, which is not sufficient for accurate diagnosis. Obstetrics, & Mastology, Faculdade de Medicina de Botucatu da Universidade Keywords: endometrial polyp • endometrial thickening • hysteroscopy • menopause Estadual Paulista “Júlio de Mesquita • transvaginal ultrasonography Filho”- UNESP- Botucatu (SP), Brasil *Author for correspondence: Tel.: +55 11 4586 0660 A progressive increase in the incidence of When comparing hysteroscopy and trans- Fax: +55 11 4586 0660 endometrial polyps has been observed with vaginal ultrasonography with pathological [email protected] 10.2217/WHE.14.50 advancing age, being more common among findings, it is conclusive that they are both postmenopausal women [1,2]. Other risk fac- complimentary methods in the diagnosis of tors have also been identified such as late uterine intracavitary lesions. menopause, obesity, hypertension and the In conclusion, this study aims to evaluate use of hormones [3]. the accuracy of transvaginal ultrasonography Currently, the most appropriate inves- and ambulatorial hysteroscopy in the diagno- 1 tigative method available for evaluating sis of endometrial polyps in postmenopausal the uterine cavity in women with endo- women. metrial thickening, either asymptomatic or with vaginal bleeding, is the hysteros- Methods 2015 copy [4], considered by many authors as Into a retrospective study, data were the ‘gold standard’ for evaluation of the obtained through the consultation records endometrium. of 323 postmenopausal women undergo- Ambulatorial hysteroscopy is a procedure ing ultrasonography and hysteroscopy (Bet- to evaluate abnormalities of the endome- tocchi) with endometrial biopsy (directed trial cavity and has a high success rate. It is by hysteroscopy). The study included 281 advisable to always perform with a biopsy if postmenopausal women, characterized by the endometrial cavity measured by ultra- the presence of at least 1 year of amenor- sonography is greater than 5 mm, and also rhea and follicle-stimulating hormonal lev- in the case of any suspected malignancy, els of at least 30 mU/ml, aged 41–82 years even when there is a normal uterine cavity old, who had undergone ambulatorial hys- part of in hysteroscopy [5]. teroscopy for submitting uterine bleeding

and/or transvaginal ultrasound (endometrial echo Results greater than or equal to 5 mm), and for these reasons, The mean age of patients was 61.3 with a standard were referred to the outpatient hysteroscopy. Some of deviation of 7.6 years. Out of these patients, 27.6% these women are users of combined hormone therapy had diabetes mellitus Type 2, 70.5% had hyperten- or tamoxifen (treatment for breast cancer). The trans- sions and 5.7% were smokers. The average BMI was vaginal ultrasound was performed using the Toshiba 31.6 with a standard deviation of 5.8 kg/m2 (minimum model SAL 38B with a 5 MHz transducer and image- of 22.51 kg/m2 and maximum of 54.10 kg/m2). Out of type mechanical sector. The measurement of endome- these patients, a further 73% were multiparous (with trial thickness was taken in the longitudinal plane at three or more births). The average time after meno- its thickest point. It encompassed both layers of the pause was 10.7 with a standard deviation of 7.7 years endometrium and myometrium was taken from the (minimum of 1 year and a maximum of 37 years) inner edge of the anterior and posterior walls of the with 15.3% of the patients being users of combined uterus including the uterine cavity. In our country, hormone therapy. It was also observed that 6.8% were ultrasonography is routinely performed on women in treatment for breast cancer with tamoxifen. Table 1 approximately once a year. 42 women were excluded shows the reasons for performing a hysteroscopy and because they had already had records with missing the ultrasonographic findings that were obtained. or incomplete reports of transvaginal ultrasonogra- It was observed that via ultrasound, an endometrial phy and diagnostic hysteroscopy, and the absence polyp was detected in 22.8% of patients. The ultra- of anatomopathological results. Demographic data, sonographic diagnoses showed endometrial thicken- clinical characteristics, justifications for hysteroscopy ing (EE) in 59.8% of the patients, being an average and sonographic, hysteroscopic and anatomopatho- of 10.5 mm with a standard deviation of 5.5 mm logic finds, were reported as mean, standard deviation, (minimum of 1 mm and a maximum of 32 mm). absolute (n) and relative (%) frequency. The perfor- The hysteroscopy diagnosed endometrial polyps in mance of tests (ultrasonography and hysteroscopy) was 80.8% of patients. Other hysteroscopy diagnostics are assessed by sensitivity, specificity, positive predictive described in Table 2. value, negative predictive value and accuracy, as well Histopathological examinations confirmed the as confidence intervals of 95%. Comparison of tests presence of 79% of endometrial polyps and 21% of in terms of sensitivity and specificity was carried out nonendometrial polyps (other findings)Table 3. by the comparison of percentages by chi-square (c²) Ultrasonography showed high sensitivity and low test, and accuracy through the Z-test for proportions. specificity, with an accuracy of 75.4%, whereas hys- The significance level was 5%. The software used for teroscopy showed high sensitivity and high specific- analysis was SAS version 9.1. ity, with an accuracy of 91.8%. The results of the

Table 1. Clinical indications of ambulatorial hysteroscopy and ultrasonographic findings for the group of women in the study. n % Indication Uterine bleeding 107 38.1 Altered ultrasonography 174 61.9 Ultrasonographic findings Normal 32 11.4 Submucosal myoma 5 1.8 Neoplasia 2 0.7 Hyperplasia 1 0.4 Thickening† 168 59.8 Endometrial polyp† 64 22.8 Endometrial polyp or submucosal fibroid† 7 2.5 Endometrial polyp or submucous myoma or 2 0.7 neoplasia† †Considered as endometrial polyps for the performance valuation of ultrasonography.

30 Womens Health (2015) 11(1) future science group Endometrial polyp in postmenopause Research Article

Table 2. Hysteroscopic findings in the group of postmenopausal women. Hysteroscopy results n % Normal 32 11.4 Submucosal myoma 8 2.8 Uterine synechiae 4 1.4 Neoplasia 3 1.1 Endometrial hyperplasia 3 1.1 Cervical polyp 1 0.4 Endometrial thickening 1 0.4 Endometrial polyp 227 80.8 Endometrial polyps/submucosal fibroids 2 0.7 diagnostic tests are shown in Table 4. The difference It was observed that ambulatorial hysteroscopy was in sensitivity, specificity and accuracy of the val- sufficient in diagnosing 96.4% of endometrial polyps. ues observed in ultrasonography and hysteroscopy Other authors, in studies of a smaller sample using the was statistically significant (p < 0.0022, p < 0.0001, same technique, diagnosed 42.1% (n = 51) of endome- p < 0.0001, respectively). trial polyps [4]. Cacciatore et al. [10] while studying postmenopausal women with uterine bleeding (n = 45) diag- Discussion nosed 42.2% (n = 19). The difference can be explained Studies have demonstrated prevalence greater than by the higher number of women included in our study. 40% of polyps in women with postmenopausal bleed- There was evidence of endometrial polyps in 222 ing [6,7]. Ben Arie et al. found endometrial polyps in patients in the anatomopathologic exam. In turn, 54.9% of asymptomatic patients, and uterine bleed- the hysteroscopy method showed a suggestive image ing in 45.1% [8]. Accordingly, we observed the preva- of polyps in 229 patients. In this sense, the disagree- lence of endometrial polyps in 79% of postmenopausal ment between the hysteroscopic image and the anato- women. In the Orvieto study [9], 65% of women were mopathological result shows that even when hysteros- diagnosed with endometrial polyps after routine ultra- copy is done by an expert, there was the possibility of a sonographic examinations, while 23% demonstrated diagnostic error. In the Campaner et al. study [4] which an image suggestive of endometrial polyps, and 75% evaluated 51 women with endometrial polyp by hyster- were presented with an irregular/thick endometrium. oscopy, histological confirmation occurred in 30 cases, In our study, there were patients with uterine bleeding which partially corroborates with our results. and asymptomatic ones, being that 22.8% of them had In a retrospective study covering 223 post an image suggestive of endometrial polyps, and 59.8% menopausal women, Kelekci [11] observed sensitivity in had endometrial thickening. the ultrasonography for the diagnosis of endometrial

Table 3. Pathological diagnosis in the study group. Pathology n % Atrophy 36 12.8 Submucosal myoma 8 2.8 Endometrioid adenocarcinoma 4 1.4 Endometrial hyperplasia 4 1.4 Chronic endometritis 3 1.1 Proliferative endometrial pattern 3 1.1 Endocervical polyp 1 0.4 Endometrial polyp 218 77.6 Endometrial polyp/simple glandular hyperplasia 1 0.4 Endometrial polyps/submucosal fibroids 2 0.7 Endometrial polyp/endocervical polyp 1 0.4

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Table 4. Accuracy of ultrasonography and hysteroscopy in the diagnosis of endometrial polyps of postmenopausal patients. Sensitivity, % Specificity, % PPV (%) NPV (%) Accuracy, % (95% CI) (95% CI) (95% CI) USG 88.7 (84.6–92.9) 25.4 (14.3–36.5) 81.7 37.5 75.4 (70.4–80.5) HSC 96.4 (93.9–98.8) 74.6 (63.5–85.7) 93.4 84.6 91.8 (88.6–95.0) p-value 0.0022 <0.0001 – – <0.0001 USG × HSC HSC: Hysteroscopy; NPV: Negative predictive value; PPV: Positive predictive value; USG: Ultrasonography.

polyps in 72% of patients, with specificity in 50.8%, through direct viewing is still a predominant element while in the hysteroscopy the sensitivity was 94.4% and in the diagnosis of endometrial polyps. On the other the specificity was 58.6%. Towbinet al. [12] observed hand, it is not possible to ensure the precise diagnosis of a sensitivity of 54 and 79% as well as a specificity of endometrial polyps by only using the ultrasonographic 90 and 93% for ultrasonography and hysteroscopy, image. respectively. In our study, ultrasonography had a sensitivity of Future perspective 88.7% and specificity of 25.4%. With hysteroscopy, With new ultrasound techniques, such as the 3D we obtained a sensitivity of 96.4% and a specificity of ultrasonography and the hysterosonography, they will 74.6%. This difference is most likely due to ultrasonog- be able to distinguish the conditions that lead to the raphy and hysteroscopy being performed by different thickening of the endometrium specifically polyps. professionals. The diagnosis of endometrial polyps is This will aggregate even more information for the strongly influenced by the diagnostic method used and conventional ultrasonography. the experience of the operating professional [8]. Yela et al. [13] demonstrated that ultrasonography and Financial & competing interests disclosure hysteroscopy showed an accuracy of 61.2 and 73.1% The authors have no relevant affiliations or financial involve- for the diagnosis of endometrial polyps, respectively. ment with any organization or entity with a financial inter- Arbozi et al. showed 60% accuracy with ultrasonogra- est in or financial conflict with the subject matter or mate- phy, [14] and Kelekci et al. [11] demonstrated 65.8% accu- rials discussed in the manuscript. This includes employment, racy with ultrasonography and 95% with hysteroscopy. consultancies, honoraria, stock ownership or options, expert Accordingly, our results also showed that diagnostic testimony, grants or patents received or pending or royalties. accuracy of ultrasonography was worse in comparison No writing assistance was utilized in the production of this with hysteroscopy for the diagnosis of endometrial pol- manuscript. yps. We never use ultrasonography as a single diagnostic method for endometrial polyps; we always perform an Ethical conduct of research ambulatorial hysteroscopy to assure proper diagnosis. The authors state that they have obtained appropriate institu- In summary, the higher accuracy rate for hyster- tional review board approval or have followed the principles oscopy, when compared with ultrasonography in the outlined in the Declaration of Helsinki for all human or animal diagnosis of endometrial polyps in postmenopausal experimental investigations. In addition, for investigations in- women, shows that sonographic evaluation may fail to volving human subjects, informed consent has been obtained identify the endometrial lesion. The cavity evaluation from the participants involved.

Executive summary Background • Endometrial polyps are common in postmenopausal women, and are often described as a thickening of the endometrium during routine transvaginal ultrasonography. Accurate diagnosis for the presence of polyps • Since most polyps are benign, a surgical approach is not always necessary. Given this, ultrasonography has the potential to be an important tool in the accurate diagnosis of endometrial polyps, and thus avoids the need of surgical procedures (i.e., hysteroscopy) for confirmation. Clinical implications • Ultrasonography fails to predict the diagnosis of endometrial polyps in postmenopausal women. Its use does not exempt the role of the hysteroscopy in confirming this pathological condition.

32 Womens Health (2015) 11(1) future science group Endometrial polyp in postmenopause Research Article

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